- Australia
Sidney Dekker
Griffith University, School of Humanities, Faculty Member
In this study we identify the differences in goal realisation when applying two conflicting paradigms regarding rule perception and management. We gathered more than 30 scenarios where goal conflicts were apparent in a military... more
In this study we identify the differences in goal realisation when applying two conflicting paradigms regarding rule perception and management. We gathered more than 30 scenarios where goal conflicts were apparent in a military operational unit. We found that operators repetitively utilized certain routines in executing their tasks in an effort to realize several conflicting goals. These routines were not originally intended nor designed into the rules and not explicitly included in documentation. They were not necessarily at odds with the literal wording and/or the intent of rules and regulations, although we did find examples of this. Our data showed that local ingenuity was created innovatively within the frame of existing rules or kept invisible to those outside the unit. The routines were introduced and passed on informally, and we found no evidence of testing for the introduction of new risks, no migration into the knowledge base of the organisation, and no dissemination as ne...
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The use of an assessment model has shown large variation (disagreement) in the scoring of airline professionals who judged the performance of a captain and first officer in multiple video scenarios. A better understanding was thus... more
The use of an assessment model has shown large variation (disagreement) in the scoring of airline professionals who judged the performance of a captain and first officer in multiple video scenarios. A better understanding was thus required of the source of assessors' disagreement in terms of both the scoring and reasoning of safety-critical crew performance and collaboration. In the first study, the present thesis quantitatively compared the scoring and assessment time of airline professionals (first officers, captains, and flight examiners) from two different airlines who were given versus not given an assessment model to judge performance. The demographics of the participants were compared in terms of their age, total flight hours, and years flown as commercial pilot. In contrast, the second and third studies qualitatively investigated and analysed assessors' reasoning further. The second study closely examined the reasoning of captain assessor pairs who assessed the perfo...
This paper investigates a largely unexplored area in criminology: the secondary victimization of professionals whose mistake has been turned into a crime. It presents the criminal prosecution of professional mistake as something that is... more
This paper investigates a largely unexplored area in criminology: the secondary victimization of professionals whose mistake has been turned into a crime. It presents the criminal prosecution of professional mistake as something that is seen a growing problem in a number of safety-critical domains such as healthcare, aviation, shipping and construction, as it may seriously threaten safety initiatives in these fields. Secondary victimization of professionals accused of crime is then explored as a possible research topic in its own right, but seen to meet obstacles related to the field of victimology, as well as the epistemological propensities in both criminology and many safety-critical domains. The paper also presents some of the possible social factors behind increasing criminalization of professional mistake, a fruitful area for social-constructionist criminology. ________________________________________________________________________
Threat and error management (TEM) is a new crucial component of pilot licensing regulations, with the aim to prepare crews with the coordinative and cogni-tive ability to handle both routine and unforeseen surprises and anomalies. In this... more
Threat and error management (TEM) is a new crucial component of pilot licensing regulations, with the aim to prepare crews with the coordinative and cogni-tive ability to handle both routine and unforeseen surprises and anomalies. In this paper we argue against a possible technicalization of threat and error management, as if they were objective variables in the environment that determined particular re-sponses. We show instead that the social processes by which the most persuasive rendering of a threat or error is constituted, says more about a crew’s ability to han-dle diversity and adversity then any successful outcome. We propose a differentia-tion between technical and normative failures, a division that has ramifications for how threat-and-error management can be taught. We conclude with a set of key indi-cators for resilient crews—crews who are capable of recognizing, adapting to, and absorbing threats and disturbances that went outside what they and their training were desig...
This study introduces and applies a new method for studying under-reporting of injuries. This method, “one-to-one injury matching”, involves locating and comparing individual incidents within company and insurer recording systems. Using... more
This study introduces and applies a new method for studying under-reporting of injuries. This method, “one-to-one injury matching”, involves locating and comparing individual incidents within company and insurer recording systems. Using this method gives a detailed measure of the difference in injuries recognised as “work-related” by the insurer, and injuries classified as “recordable” by the company. This includes differences in the volume of injuries, as well as in the nature of the injuries. Applying this method to an energy company shows that only 19% of injuries recognised by the insurer were recognised by the company as recordable incidents. The method also demonstrates where claiming behaviour and claims management have created systematic biases in the disposition of incidents. Such biases result in an inaccurate picture of the severity and nature of incidents, over-estimating strike injuries such as to the hand, and underestimating chronic and exertion injuries such as to th...
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A broad issue in cognitive systems engineering is at stake here. If we want to learn from practitioners’ interactions with each other and technology, we need to study their practice. Process tracing methods are part of a larger family of... more
A broad issue in cognitive systems engineering is at stake here. If we want to learn from practitioners’ interactions with each other and technology, we need to study their practice. Process tracing methods are part of a larger family of cognitive task analysis but aim specifically to analyze how people’s understanding evolved in parallel with the situation unfolding around them during a particular problem-solving episode. Process tracing methods are extremely useful, if not indispensable, in the investigation of incidents and accidents.
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This paper discusses the literature that shows that declaring a zero vision for everything bad (including unsafe behaviours, incidents, injuries) does not prevent fatalities or major accidents. In fact, parts of the literature show that a... more
This paper discusses the literature that shows that declaring a zero vision for everything bad (including unsafe behaviours, incidents, injuries) does not prevent fatalities or major accidents. In fact, parts of the literature show that a reduction in minor badness increases the risk of major accidents and fatalities. This is true in several industries. Two families of explanations are discussed. The first is the concern that declaring a zero vision can reduce operational knowledge. The second is the unsubstantiated assumption that minor injuries and fatalities have the same causal pattern. In general, evidence for or against the utility of a zero vision is dogged by confouding factors (other variables responsible for changes in safety outcomes) and what Giddens called the double hermeneutic, where the results of such studies are only as stable as the attributions the original reporter (e.g. OHS official, case worker) and the subsequent analyst (e.g. researcher) made about a particu...
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The language we use to describe the past can have a strong influence on the audience’s interpretation of our story. In our experiment, we explore, using 3 different conditions, how the framing and language of an accident report can affect... more
The language we use to describe the past can have a strong influence on the audience’s interpretation of our story. In our experiment, we explore, using 3 different conditions, how the framing and language of an accident report can affect the audience’s proposed solutions to manage the problems found. We find that the approach used to create an accident report can have a powerful influence on the audience’s decision making. Whether we are describing an accident in a similar manner to a crime, using a systems approach or we are accepting of multiple stories which are not linear or coherent, the methods we use to capture and communicate the story have a profound impact on the actions decided upon by the reader.
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This paper describes and illustrates the use of a general methodology for knowledge elicitation to enable better prediction of the human factors implications of future system designs. Specifically, this approach involves the following... more
This paper describes and illustrates the use of a general methodology for knowledge elicitation to enable better prediction of the human factors implications of future system designs. Specifically, this approach involves the following steps:1. Identifying critical factors that could influence performance in the future system.2. Using this list of factors to predict incidents that could plausibly arise in the future system.3. Designing realistic, detailed incident reports based on these predicted incidents.4. Asking a group of experienced practitioners representing different perspectives in the current system to act as a review team by evaluating a reported incident and identifying the important issues and implications it raises.5. Using the insights generated by the discussions of the review team to provide guidance in making decisions about the implementation of the future system.To illustrate the use of this methodology, a scenario was developed. This scenario was based on experiences with the expanded ...
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Handover—the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis (defined by British... more
Handover—the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis (defined by British Medical Association, and adopted by Australian Medical Associatio
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This article examines the emergence of "accurate situation awareness (SA)" as a legal and moral standard for judging professional negligence in medicine. It argues that SA constitutes a status, an outcome resulting from the... more
This article examines the emergence of "accurate situation awareness (SA)" as a legal and moral standard for judging professional negligence in medicine. It argues that SA constitutes a status, an outcome resulting from the confluence of a wide array of factors, some originating inside and others outside the agent. SA does not connote an action, a practice, a role, a task, a virtue, or a disposition--the familiar objects of moral and legal appraisal. The argument contends that invoking SA becomes problematic when its use broadens to include professional or legally appraisable norms for behaviour, which expect a certain state of awareness from practitioners.
Research Interests: Psychology, Social Psychology, Epistemology, Situation awareness, Medical Ethics, and 15 moreMedicine, Humans, Philosophy and Religious Studies, Virtue, Disposition, Law and Medicine, Awareness, Malpractice, Morals, Accident analysis, Clinical Competence, Bolam Test, Medical staff, Law and Legal Studies, and Medical and Health Sciences
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Research Interests: Accountability, Health Care, Health Services Research, Health Administration, Medicine, and 8 moreInterdisciplinary research (Social Sciences), Emergency Medical Services, Library and Information Studies, Humans, Personnel Management, Theoretical Models, Public health systems and services research, and Emergencies
In this paper, we discuss the grounding of the Royal Majesty, reconstructed from the perspective of the crew. The aim is particularly to understand the role of automation in shaping crew assessments and actions. Automation is often... more
In this paper, we discuss the grounding of the Royal Majesty, reconstructed from the perspective of the crew. The aim is particularly to understand the role of automation in shaping crew assessments and actions. Automation is often introduced because of quantitative promises that: it will reduce human error; reduce workload; and increase efficiency. But as demonstrated by the Royal Majesty, as well as by numerous research results, automation has qualitative consequences for human work and safety, and does not simply replace human work with machine work. Automation changes the task it was meant to support; it creates new error pathways, shifts consequences of error further into the future and delays opportunities for error detection and recovery. By going through the sequence of events that preceded the grounding of the Royal Majesty, we highlight the role that automation plays in the success and failure of navigation today. We then point to future directions on how to make automated...
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A recent conversation in the literature asks whether human factors constructs amount to folk modeling or to strong science. In this paper we explore this further in the context of well-known positions on the production of science and... more
A recent conversation in the literature asks whether human factors constructs amount to folk modeling or to strong science. In this paper we explore this further in the context of well-known positions on the production of science and scientific rationality. We inquire about the sources of epistemological self-confidence—the extent to which human factors is satisfied with its beliefs and assumptions about how it knows what it knows. We question whether a large body of evidence for a construct is evidence of strong science, or whether critical reflection and skepticism about this is actually what distinguishes scientific knowledge from folk models. We also review presumptions of a-perspectival objectivity, in which researchers believe they are able to take a “view from nowhere” and enjoy an objective window onto an existing reality. We ask whether human factors constructs don't so much reflect but rather create a particular empirical world, which would not even exist without those...
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Medical negligence has been the subject of much public debate in recent decades. Although the steep increase in the frequency and size of claims against doctors at the end of the last century appears to have plateaued, in Australia at... more
Medical negligence has been the subject of much public debate in recent decades. Although the steep increase in the frequency and size of claims against doctors at the end of the last century appears to have plateaued, in Australia at least, medical indemnity costs and consequences are still a matter of concern for doctors, medical defence organisations and governments in most developed countries. Imprecision in the legal definition of negligence opens the possibility that judgments of this issue at several levels may be subject to hindsight and outcome bias. Hindsight bias relates to the probability of an adverse event perceived by a retrospective observer ("I would have known it was going to happen"), while outcome bias is a largely subconscious cognitive distortion produced by the observer's knowledge of the adverse outcome. This review examines the relevant legal, medical, psychological and sociological literature on the operation of these pervasive and universal b...
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This empirical study investigated the qualitative effects of controller-pilot datalink communication on talk and work inside the flight deck as well as issues related to the chosen interface for the technology. Line operations using... more
This empirical study investigated the qualitative effects of controller-pilot datalink communication on talk and work inside the flight deck as well as issues related to the chosen interface for the technology. Line operations using datalink communication between the air traffic controller and the aircrafts in controller-pilot datalink Northern European airspace were observed over a period of 11 months to document the transformations of cockpit communications and coordinative patterns. Findings show that controller-pilot datalink easily takes precedence over other cockpit tasks, especially during higher-tempo operations. Other findings indicate that controller-pilot datalink changes and erodes some of the redundancy previously inherent in receiving clearances by voice communication, and that it blurs the roles of pilot-flying and pilot-not-flying. In addition, the interface for controller-pilot datalink messages can interfere with the presentation of other flight-related data. Befor...
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This paper investigates a largely unexplored area in criminology: the secondary victimization of professionals whose mistake has been turned into a crime. It presents the criminal prosecution of professional mistake as something that is... more
This paper investigates a largely unexplored area in criminology: the secondary victimization of professionals whose mistake has been turned into a crime. It presents the criminal prosecution of professional mistake as something that is seen a growing problem in a number of safety-critical domains such as healthcare, aviation, shipping and construction, as it may seriously threaten safety initiatives in these fields. Secondary victimization of professionals accused of crime is then explored as a possible research topic in its own right, but seen to meet obstacles related to the field of victimology, as well as the epistemological propensities in both criminology and many safety-critical domains. The paper also presents some of the possible social factors behind increasing criminalization of professional mistake, a fruitful area for social-constructionist criminology.
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We had the opportunity to study four different organizations over a period of two years in their efforts to improve their learning from failure. While we were able to distinguish six stages in an organization's growth to embracing the... more
We had the opportunity to study four different organizations over a period of two years in their efforts to improve their learning from failure. While we were able to distinguish six stages in an organization's growth to embracing the "new view" of human error and system safety, it was more difficult to assess why some of the organizations studied were less successful than others, probably because of the very complex picture underlying an organization's willingness to learn and improve.
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New aircraft come with a set of recommended standard operating procedures, in the case of multi-crew aircraft this includes "callouts"-verbalizations of particular flight guidance automation mode changes. In an attempt to reduce... more
New aircraft come with a set of recommended standard operating procedures, in the case of multi-crew aircraft this includes "callouts"-verbalizations of particular flight guidance automation mode changes. In an attempt to reduce the risk for mode confusion some operators have required flight crews to callout all flight guidance automation mode changes as a means of forcing pilots to monitor the Flight Mode Annunciator (FMA). Previous research has shown that crews do not spend enough time on the flight mode annunciator, and skip mode call-outs as well as making call-outs in advance of annunciations; there has been no report of any system or regularity in the shedding and adaptation of callouts. One reason could be the contrived empirical simulator settings of such research, which we aimed to augment with natural observations of real cockpit work reported here. With the hope of answering, in more detail, how required verbal coordination of annunciated mode changes gets adapt...
Threat and error management (TEM) is a new crucial component of pilot licensing regulations, with the aim to prepare crews with the coordinative and cogni- tive ability to handle both routine and unforeseen surprises and anomalies. In... more
Threat and error management (TEM) is a new crucial component of pilot licensing regulations, with the aim to prepare crews with the coordinative and cogni- tive ability to handle both routine and unforeseen surprises and anomalies. In this paper we argue against a possible technicalization of threat and error management, as if they were objective variables in the environment that determined particular re- sponses. We show instead that the social processes by which the most persuasive rendering of a threat or error is constituted, says more about a crew's ability to han- dle diversity and adversity then any successful outcome. We propose a differentia- tion between technical and normative failures, a division that has ramifications for how threat-and-error management can be taught. We conclude with a set of key indi- cators for resilient crews—crews who are capable of recognizing, adapting to, and absorbing threats and disturbances that went outside what they and their training w...
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INTRODUCTION The professional identity of safety professionals is rife with unresolved contradictions and tensions. Are they advisor or instructor, native or independent, enforcer of rules or facilitator of front-line agency, and... more
INTRODUCTION The professional identity of safety professionals is rife with unresolved contradictions and tensions. Are they advisor or instructor, native or independent, enforcer of rules or facilitator of front-line agency, and ultimately, a benefactor for safety or an organizational burden? Perhaps they believe that they are all of these. This study investigated professional identity through understanding what safety professionals believe about safety, their role within organizations, and their professional selves. Understanding the professional identity of safety professionals provides an important foundation for exploring their professional practice, and by extension, understanding organizational safety more broadly. METHOD An embedded researcher interviewed 13 senior safety professionals within a single large organization. Data were analyzed using grounded theory methodology. The findings were related to a five-element professional identity model consisting of experiences, attributes, motives, beliefs, and values, and revealed deep tensions and contradictions. This research has implications for safety professionals, safety professional associations, safety educators, and organizations.
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This article examines the emergence of “accurate situation awareness (SA)” as a legal and moral standard for judging professional negligence in medicine. It argues that SA constitutes a status, an outcome resulting from the confluence of... more
This article examines the emergence of “accurate situation awareness (SA)” as a legal and moral standard for judging professional negligence in medicine. It argues that SA constitutes a status, an outcome resulting from the confluence of a wide array of factors, some originating inside and others outside the agent. SA does not connote an action, a practice, a role, a task, a virtue, or a disposition – the familiar objects of moral and legal appraisal. The argument contends that invoking SA becomes problematic when its use broadens to include professional or legally appraisable norms for behaviour, which expect a certain state of awareness from practitioners.
Research Interests: Psychology, Epistemology, Situation awareness, Medical Ethics, Negligence (Medical Law), and 13 moreMedicine, Humans, Philosophy and Religious Studies, Law and Medicine, Awareness, Malpractice, Morals, Accident analysis, Clinical Competence, Bolam Test, Medical staff, Law and Legal Studies, and Medical and Health Sciences
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Subcontractors have always been linked to higher risk by the industry and academia. However, not much work exists in establishing the reasons behind this relationship. Much of the existing work, either categorise subcontractors under a... more
Subcontractors have always been linked to higher risk by the industry and academia. However, not much work exists in establishing the reasons behind this relationship. Much of the existing work, either categorise subcontractors under a theoretical label of work to apply the drawbacks of the label to them, or directly enter problem-solving mode. This study focusses on taking the perspective of subcontractors and explores ways in which this viewpoint interacts with safety systems and processes. This study applies a case study methodology to this problem. It examines a total of six cases reflecting six closed single subcontractor fatality accident investigation reports from the year 2004 to 2014 obtained from the Department of Natural Resources and Mines (DNRM) Queensland. These cases are then thematically analysed by employing subcontractor theory to identify themes to categorise the links between higher risk and subcontractors. The themes identified match two pre-existing categories ...
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The language and approach we use to describe the past can have a strong influence on the audience’s interpretation of our story. In our experiment, we explore, using 3 different conditions, how the framing, language and style of an... more
The language and approach we use to describe the past can have a strong influence on the audience’s interpretation of our story. In our experiment, we explore, using 3 different conditions, how the framing, language and style of an accident report can affect the audience’s proposed solutions to manage the problems found. We find that the approach used to create an accident report can have a powerful influence on the audience’s decision making. Whether we are describing an accident in a linear manner, using a systems approach, or we are accepting of multiple stories which are not linear or coherent, the methods we use to capture and communicate the story have a profound impact on the actions decided upon by the reader.
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Restorative justice is an approach that aims to replace hurt by healing in the understanding that the perpetrators of pain are also victims of the incident themselves. In 2016, Mersey Care, an NHS community and mental health trust in the... more
Restorative justice is an approach that aims to replace hurt by healing in the understanding that the perpetrators of pain are also victims of the incident themselves. In 2016, Mersey Care, an NHS community and mental health trust in the Liverpool region, implemented restorative justice (or what it termed a 'Just and Learning Culture') to fundamentally change its responses to incidents, patient harm, and complaints against staff. Although qualitative benefits from this implementation seemed obvious, it was also thought relevant to identify the economic effects of restorative justice. Through interviews with Mersey Care staff and collecting data pertaining to costs, suspensions, and absenteeism, an economic model of restorative justice was created. We found that the introduction of restorative justice has coincided with many qualitative improvements for staff, such as a reduction in suspensions and dismissals, increase in the reporting of adverse events, increase in the numbe...
Recent high-visibility disasters have fueled public and political awareness of the importance of managing and mitigating their consequences effectively. In response, various countries have enacted legislation that demands the evaluation... more
Recent high-visibility disasters have fueled public and political awareness of the importance of managing and mitigating their consequences effectively. In response, various countries have enacted legislation that demands the evaluation of emergency responses so that lessons for improvement can be learned. A series of field and experimental studies were conducted from 2005 to 2007 to assess the ability of firstresponder organizations (eg, fire departments) to learn from failures that occurred during their emergency responses. The departments studied often lacked basic organizational requisites for effectively learning from failure (eg, mutual trust, participation, knowledge of possible learning mechanisms). Further, neither firstresponder training, nor daily practice, seems supported by knowledge of generic competencies necessary for effective crisis management. This not only hampers coordination during a response, but also keeps its evaluation from using a language that could help ...
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Automation surprises in aviation continue to be a significant safety concern and the community’s search for effective strategies to mitigate them are ongoing. The literature has offered two fundamentally divergent directions, based... more
Automation surprises in aviation continue to be a significant safety concern and the community’s search for effective strategies to mitigate them are ongoing. The literature has offered two fundamentally divergent directions, based on different ideas about the nature of cognition and collaboration with automation. In this paper, we report the results of a field study that empirically compared and contrasted two models of automation surprises: a normative individual-cognition model and a sensemaking model based on distributed cognition. Our data prove a good fit for the sense-making model. This finding is relevant for aviation safety, since our understanding of the cognitive processes that govern the human interaction with automation drives what we need to do to reduce the frequency of automation-induced events.